Healthcare Provider Details

I. General information

NPI: 1841404027
Provider Name (Legal Business Name): AMANDA WHERRY OTR L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 W COLT SQUARE DR
FAYETTEVILLE AR
72703-2813
US

IV. Provider business mailing address

PO BOX 9626
FAYETTEVILLE AR
72703-0028
US

V. Phone/Fax

Practice location:
  • Phone: 479-587-9201
  • Fax: 479-527-9439
Mailing address:
  • Phone: 479-587-9201
  • Fax: 479-527-9439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOTR2095
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: